Trends in the Burden of Diabetes, High Blood Pressure, and Cardiovascular Disease in Utah 2010

1. Trends in the Burden of Diabetes, High Blood Pressure, and Cardiovascular Disease in Utah 2010 MaryCatherine Jones, MPHEpidemiologist Heart Disease & Stroke Prevention ProgramUtah Department of Health Pause for 3 seconds.Pause for 3 seconds.

3. Diabetes in Utah

4. Diabetes Prevalence: Utah

5. Diabetes Prevalence: Utah

6. Diabetes Prevalence: Utah

8. Diabetes and Cardiovascular Disease Heart disease death rates among adults with DM are 2-4x higher than the rates for adults without DM. Having DM increased the risk of developing CVD by 2.5X for women and 2.4X for men. The relative risk of CHD was 1.38X higher for each 10 year increase in duration of DM. Heart disease death rates among adults with DM are 2-4x higher than the rates for adults without DM. Having DM increased the risk of developing CVD by 2.5X for women and 2.4X for men. The relative risk of CHD was 1.38X higher for each 10 year increase in duration of DM.

9. Utah Coronary Heart Disease Deaths, 1999-2009

10. Utah Stroke Deaths,1999-2009

12. Utah Hospital Discharges In this 16-year period, hospital discharges declined for each of these three types of cardiovascular disease. Heart failure hospitalizations continue to be high. Coronary heart disease hospitalizations had the largest decrease over the 16 year period.In this 16-year period, hospital discharges declined for each of these three types of cardiovascular disease. Heart failure hospitalizations continue to be high. Coronary heart disease hospitalizations had the largest decrease over the 16 year period.

13. CVD Hospital Discharges

14. The Trends

15. Diabetes Prevalence: Utah The rate of diabetes has doubled since 1989.The rate of diabetes has doubled since 1989.

16. High Blood Pressure: Utah Prevalence of HBP and HBC are important indicators of cardiovascular health in Utah. High blood pressure data has increased by 18% since 1995. High cholesterol has increased by 36% since 1991.Prevalence of HBP and HBC are important indicators of cardiovascular health in Utah. High blood pressure data has increased by 18% since 1995. High cholesterol has increased by 36% since 1991.

17. High Cholesterol: Utah

18. Overweight or Obesity: Utah Not-so-good news. The odds of stroke death are 4.4x higher for people who are obese. Although Utah is one of the most active states, more than half of our residents are overweight or obese. Not-so-good news. The odds of stroke death are 4.4x higher for people who are obese. Although Utah is one of the most active states, more than half of our residents are overweight or obese.

19. National trends document an increase in physical activity from 1980-2000. Utah has consistently ranked as one of the most active states in the US.National trends document an increase in physical activity from 1980-2000. Utah has consistently ranked as one of the most active states in the US.

20. Cigarette Smoking: Utah Smoking increases risk of CHD death by 2 to 3X. Nationally, declines in cigarette smoking have contributed significantly to the overall decline in coronary heart disease mortality. Utah continues to have the lowest smoking rate in the country. Smoking increases risk of CHD death by 2 to 3X. Nationally, declines in cigarette smoking have contributed significantly to the overall decline in coronary heart disease mortality. Utah continues to have the lowest smoking rate in the country.

21. The Institute of Medicine Report on Hypertension “A Neglected Disease” The importance of preventing and controlling high blood pressure is increasingly documented in research of cardiovascular disease mortality. The CDC’s Division of Heart Disease & Stroke Prevention is encouraging states to consider evidence-based strategies with their partners in addressing high blood pressure. ***NOTE: The slides in this section are based on the IOM report. Content is based on national-level data.The importance of preventing and controlling high blood pressure is increasingly documented in research of cardiovascular disease mortality. The CDC’s Division of Heart Disease & Stroke Prevention is encouraging states to consider evidence-based strategies with their partners in addressing high blood pressure. ***NOTE: The slides in this section are based on the IOM report. Content is based on national-level data.

22. High Blood Pressure

23. A “Neglected Disease” In its landmark report, the Institute of Medicine called high blood pressure a “neglected disease.” Simply put, HBP is easily diagnosed and evidence-based therapies exist. However, many patients with HBP are untreated or have inadequate treatment. The IOM committee completed a thorough literature review in preparation of the report. The report cites barriers to treatment within the health care system and underscores that systems must change in order to achieve population-wide improvement. In its landmark report, the Institute of Medicine called high blood pressure a “neglected disease.” Simply put, HBP is easily diagnosed and evidence-based therapies exist. However, many patients with HBP are untreated or have inadequate treatment. The IOM committee completed a thorough literature review in preparation of the report. The report cites barriers to treatment within the health care system and underscores that systems must change in order to achieve population-wide improvement.

24. “Knowing is not enough; we must apply. Willing is not enough; we must do.” -Goethe

25. Inadequate Primary Care “Lack of physician adherence to HBP treatment guidelines is a major problem and significant reason for the lack of awareness, lack of pharmacological treatment, and lack of hypertension control in the United States.”

26. Inadequate Primary Care Physicians are unlikely to treat or to intensify treatment for mild to moderate systolic HBP (<165mmHg) if the DBP <90mmHg Few physicians encourage patients to make lifestyle modifications that are known to be effective in controlling HBP.

27. HBP Medication Compliance 50% of patients discontinue drug treatment after 1 year. Noncompliance with HBP meds = increased hospital admissions. Continuous HBP medications = staying on meds costs less than hospitalizing patients 50% of patients discontinue drug treatment after 1 year. Noncompliance with HBP meds = increased hospital admissions. Continuous HBP medications = statistically significant reductions in hospital expenditures per patient that are greater than the accompanying drug costs.50% of patients discontinue drug treatment after 1 year. Noncompliance with HBP meds = increased hospital admissions. Continuous HBP medications = statistically significant reductions in hospital expenditures per patient that are greater than the accompanying drug costs.

28. HBP Medication Compliance

29. A Sentinel Indicator for Disparities Nationally, high blood pressure is associated with racial and ethnic health disparities. These disparities occur along the entire spectrum from risk factors to the delivery of medical care. Targeting interventions toward a general population historically do not correct these inequities and can even worsen them. ***This is based on national-level data. Section below taken directly from p.29 of IOM report on hypertension: “Hypertension as a Sentinel Indicator for Health Disparities Hypertension is a disease for which there are major inequities across racial groups and economic groups—along the entire spectrum from risk factors to delivery of medical care. Interventions directed toward general population groups historically do not correct these inequities and can even worsen them. Care must be taken to assure that any portfolio of interventions implemented will minimize existing inequities in prevention, detection, treatment, and control of hypertension. Hypertension is a condition strongly influenced by underlying individual and community risk factors related to healthy eating and active living—risk factors driven by race and class in most communities today. As such, it is a potential sentinel indicator for assessing and testing broader approaches to reduce health disparities. The prevalence of hypertension may provide a relatively quick and objective measure of programs directed at these risk factors as well as underlying social determinants of health. Hypertension, while treatable, requires ongoing access to primary care for maximum effectiveness. As such, it is also a potentially very good marker for lack of access to or continuity of health care in a community. SLHJs should consider hypertension as a sentinel measure for evaluation of the effectiveness of a range of disparity-reducing activities, including important place-based strategies tackling conditions through community policy interventions.”***This is based on national-level data. Section below taken directly from p.29 of IOM report on hypertension: “Hypertension as a Sentinel Indicator for Health Disparities Hypertension is a disease for which there are major inequities across racial groups and economic groups—along the entire spectrum from risk factors to delivery of medical care. Interventions directed toward general population groups historically do not correct these inequities and can even worsen them. Care must be taken to assure that any portfolio of interventions implemented will minimize existing inequities in prevention, detection, treatment, and control of hypertension. Hypertension is a condition strongly influenced by underlying individual and community risk factors related to healthy eating and active living—risk factors driven by race and class in most communities today. As such, it is a potential sentinel indicator for assessing and testing broader approaches to reduce health disparities. The prevalence of hypertension may provide a relatively quick and objective measure of programs directed at these risk factors as well as underlying social determinants of health. Hypertension, while treatable, requires ongoing access to primary care for maximum effectiveness. As such, it is also a potentially very good marker for lack of access to or continuity of health care in a community. SLHJs should consider hypertension as a sentinel measure for evaluation of the effectiveness of a range of disparity-reducing activities, including important place-based strategies tackling conditions through community policy interventions.”

30. High blood pressure: The burden in utah

31. High Blood Pressure Diagnoses Prevalence curve appears to be exponential. Two reasons: 1) HBP prevalence increases with advanced age, 2) physicians may be more likely to diagnose it in older adults.Prevalence curve appears to be exponential. Two reasons: 1) HBP prevalence increases with advanced age, 2) physicians may be more likely to diagnose it in older adults.

32. High Blood Pressure Prevalence As in the US, age is the strongest risk factor for HBP. Men have a higher prevalence of HBP until the oldest category, 65+. As in the US, age is the strongest risk factor for HBP. Men have a higher prevalence of HBP until the oldest category, 65+.

33. High Blood Pressure Prevalence High blood pressure prevalence decreases in the highest income and educational categories. High blood pressure prevalence decreases in the highest income and educational categories.

34. High Blood Pressure Prevalence Other non-Hispanics have significantly higher rates of HBP compared to all Utahns. This is consistent with national trends. • According to 2005–06 data from NCHS, blood pressure control rates were lower among Mexican Americans (35.2 percent) than non-Hispanic Whites (46.1 percent) and non-Hispanic blacks (46.5 percent). (NCHS Data Brief No. 3; 2008.)Other non-Hispanics have significantly higher rates of HBP compared to all Utahns. This is consistent with national trends. • According to 2005–06 data from NCHS, blood pressure control rates were lower among Mexican Americans (35.2 percent) than non-Hispanic Whites (46.1 percent) and non-Hispanic blacks (46.5 percent). (NCHS Data Brief No. 3; 2008.)

35. High Blood Pressure Prevalence Consistent with national data, Utah’s HBP rate among African Americans is more than a third (35.5%) higher than the state rate. According to national studies, compared to whites, blacks develop HBP earlier in life and their average BPs are much higher. As a result, compared to whites, blacks have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of death due to HD, and a 4.2 times greater rate of end-stage kidney disease (source: AHA statistical update 2010). Analysis of NHANES/NCHS data from 1999–2004 through 2005–06 revealed substantial increases in awareness and treatment of hypertension. Control rates increased in both sexes, non-Hispanic blacks and Mexican Americans. (NCHS. Hypertension Awareness, Treatment and Control: Continued Disparities in Adults, United States, 2005–06. NCHS Data Brief No. 3, 2008.) Consistent with national data, Utah’s HBP rate among African Americans is more than a third (35.5%) higher than the state rate. According to national studies, compared to whites, blacks develop HBP earlier in life and their average BPs are much higher. As a result, compared to whites, blacks have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of death due to HD, and a 4.2 times greater rate of end-stage kidney disease (source: AHA statistical update 2010). Analysis of NHANES/NCHS data from 1999–2004 through 2005–06 revealed substantial increases in awareness and treatment of hypertension. Control rates increased in both sexes, non-Hispanic blacks and Mexican Americans. (NCHS. Hypertension Awareness, Treatment and Control: Continued Disparities in Adults, United States, 2005–06. NCHS Data Brief No. 3, 2008.)

36. HBP in Utah

37. Taking Medication to Control HBP This slide reflects the percentage of Utahns who reported having been told they had high blood pressure and also said they were taking medication to control it.This slide reflects the percentage of Utahns who reported having been told they had high blood pressure and also said they were taking medication to control it.

38. HBP in Utah: Conclusions Although HBP is associated with age, many factors influence its distribution across other demographic groups. Older, lower-income, less-educated, and racial and ethnic minority populations bear a higher burden. Approaches targeting the “general” population are unlikely to resolve disparities. The health care system must use comprehensive evidence-based approaches to support lifestyle change and medical management to adequately address the high prevalence of co-occurring risk factors and co-morbid conditions among people with HBP. Public health agencies and partners must continue to advocate for policies and processes that improve high blood pressure prevention and control. Although HBP is associated with age, many factors influence its distribution across other demographic groups. Older, lower-income, less-educated, and racial and ethnic minority populations bear a higher burden. Approaches targeting the “general” population are unlikely to resolve disparities. The health care system must use comprehensive evidence-based approaches to support lifestyle change and medical management to adequately address the high prevalence of co-occurring risk factors and co-morbid conditions among people with HBP. Public health agencies and partners must continue to advocate for policies and processes that improve high blood pressure prevention and control.

39. The institute of medicine report on sodium 2010 39 On the heels of the IOM report on hypertension, the IOM issued another report in March 2010, describing the public health importance of sodium. Consuming a diet high in sodium can complicate the treatment of high blood pressure. On the heels of the IOM report on hypertension, the IOM issued another report in March 2010, describing the public health importance of sodium. Consuming a diet high in sodium can complicate the treatment of high blood pressure.

40. 40 Excess sodium intake is a primary risk factor for high blood pressure. High sodium intake also makes it hard to control high blood pressure. Most of the sodium in our food supply is invisible in processed and restaurant foods. Consumers have little control over the amount of sodium in their diet.  It can be difficult for even the most motivated consumer to reduce sodium intake.  Sodium Reduction: A Public Health Imperative

41. Sources of Sodium 41

42. Sodium Intake Recommendations The 2005 Dietary Guidelines for Americans recommend less than 2,300 mg per day for the general population. For specific populations—70 percent of U.S. adults—limit intake to 1,500 mg per day. Average daily sodium intake for U.S. adults is more than 3,400 mg per day. 42

43. 43 Estimated Effects on HBP Prevalence and Related Costs from Sodium Reduction Even fewer cases of HBP and more dollars saved if intake was reduced to 1,500 mg per day (recommended maximum level for “specific populations”). Even fewer cases of HBP and more dollars saved if intake was reduced to 1,500 mg per day (recommended maximum level for “specific populations”).

44. What Has Been Done to Reform the Norm Abroad? Several countries have taken action on sodium reduction. Finland: Significant decrease in average population salt intake. United Kingdom: Reduced average sodium intake by 360 mg. Canada: Sodium Working Group formed in 2007. 44

45. International: Product Variability 45

46. National Salt Reduction Initiative New York City DOH launched a nationwide effort to reduce the level of salt in processed and restaurant foods. Includes more than 40 cities, states, and public health organizations. Works with food industry representatives voluntarily to reduce the salt in their products. Initial sodium reduction benchmarks have been set for 61 categories of packaged foods and 25 categories of restaurant foods. UDOH is in the process of getting approval to join this effort. 46

47. Potential State and Local Strategies Consumer awareness campaigns. Letter-writing campaigns. Consumer awareness campaigns. Letter-writing campaigns.

48. Healthier Food Environment = Healthier Population 48 Changing the food environment gives consumers a broader range of healthful foods from which to choose. Policy and environment strategies are effective at the state and local level and help drive demand for federal action. Lowering sodium content of processed and restaurant foods is one of the most promising strategies to decrease the prevalence of heart disease and stroke. Sodium reduction will benefit most Americans. Changing the food environment gives consumers a broader range of healthful foods from which to choose. Policy and environment strategies are effective at the state and local level and help drive demand for federal action. Lowering sodium content of processed and restaurant foods is one of the most promising strategies to decrease the prevalence of heart disease and stroke. Sodium reduction will benefit most Americans.

49. Counseling Patients Educate patients about sodium and high blood pressure Foods high in sodium do not necessarily taste “salty.” Foods labeled “heart healthy” do not necessarily have low sodium content. Reading nutritional labels is key to identifying high sodium products.

50. Counseling Patients Follow up with patients by asking what they are doing to lower their sodium intake. Work with patients to set goals around healthy diet and choosing low sodium foods.

51. Additional Resources CDC’s Division for Heart Disease and Stroke Prevention Salt Web page http://www.cdc.gov/salt  Institute of Medicine, Strategies to Reduce Sodium in the United States http://www.iom.edu/sodiumstrategies Institute of Medicine, A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension http://www.iom.edu/Reports/2010/A-Population-Based-Policy-and-Systems-Change-Approach-to-Prevent-and-Control-Hypertension.aspx 51

52. Thank you! MaryCatherine Jones, MPH Heart Disease & Stroke Prevention Program Utah Department of Health (801) 538-6536 mcjones@utah.gov